Robert Finlay-Jones

The prevalence of minor psychiatric morbidity in the community.

The method is described of a point-prevalence survey of minor psychiatric morbidity among a sample of healthy community residents. The General Health Questionnaire was used as the sole means of case identification. The demographic characteristics of the sample were compared in detail with those of the total population. The factors mainly responsible for sample bias were difficulty with the English language, the varying degree of personal contact made with residents, and the difficulty in contacting the employed population during working hours. The overall response rate of the survey was 66-2%. The demographic groups found to be at significantly higher risk for minor psychiatric morbidity included women, the young, non-British migrant women, and lower social class men.

Contrasting demographic patterns of minor psychiatric morbidity in general practice and the community.

The 60-item General Health Questionnaire was completed by 90% of 4798 patients aged 15--69 years who consulted, on one day, the general practitioners of 97% of practices in the Perth Statistical Division. A point prevalence rate of minor psychiatric morbidity in various demographic groups was calculated in terms of the population at risk. The demographic pattern of morbidity was compared with that found in a probability sample of 2324 community residents drawn from the same population at risk, and surveyed at the same time using the same time using the same screening instrument. Widowed persons, British-born men who had recently migrated to Australia, and lower-social-class men with minor psychiatric morbidity were under-represented in general practice. Elderly men and women in upper-class occupations with minor psychiatric morbidity were over-represented in general practice. These differences, unlike others that were found, could not be explained by differing consulting habits or by differing completion rates of the screening instrument.

Antisocial personality disorder, psychopathy and injecting heroin use

Two hundred community-based methadone patients (CM); 200 prison inmates enrolled in prison methadone programs (PM); and 150 prison inmates with no history of heroin use (PNH) were interviewed to obtain diagnoses of antisocial personality disorder (ASPD) and Psychopathy Checklist-defined psychopathy. Large proportions of subjects in all three groups met the criteria for a diagnosis of ASPD (CM 44%, PM 65%, PNH 31%), with the two methadone groups having significantly higher proportions of ASPD diagnoses than non-heroin users. There were no differences between groups in the proportions diagnosed as psychopathic (CM 4%, PM 9%, PNH 4%). For each group, the proportions diagnosed as ASPD were significantly higher than the proportions diagnosed as psychopathic. Implications for the diagnosis of ASPD are discussed.

The onset of heroin use and criminal behaviour: does order make a difference?

The extent to which the onset of criminality with respect to heroin use accounts for heterogeneity within a heroin-using population was investigated among 400 community and incarcerated methadone maintenance patients. Those for whom crime preceded heroin use (primary antisocials) were younger and more likely to be male than those for whom heroin use preceded crime (secondary antisocials). Primary antisocials were also more likely to have committed violent crime and to qualify for a diagnosis of antisocial personality disorder (ASPD). It is concluded that taking the order of onset of heroin use and criminality into account may reduce the risk of overdiagnosing ASPD among this population and help clarify the relationship between drug use and crime.

Anti-social personality disorder and response to methadone maintenance treatment.

A sample of 183 current methadone maintenance patients were interviewed on their drug use history, criminal history, current drug use, and symptoms of Anti-social Personality Disorder (ASPD). Thirty-nine percent of patients met the DSM-III-R criteria for a diagnosis of ASPD. ASPD patients had an earlier onset of drug use, drug injecting, heroin use, had wider polydrug using histories and had been arrested earlier and more frequently than other patients. Despite the different pretreatment histories of ASPD and other patients, there were no differences between the two groups in retention in treatment, methadone dosage or heroin use. It is concluded that heroin-dependent ASPD patients can be successfully retained in methadone treatment, on similar methadone doses and with similar in-treatment drug use patterns as those of non-ASPD heroin dependent patients.

A Consensus Conference on Psychotic Depression

We report a consensus conference on psychotic depression that addressed historic, classification, phenomenologic, epidemiologic, aetiologic, management and outcome issues. We were able to detail the impact of the information offered by having audience members complete questionnaires before and after the conference. The respondents indicated that the status of psychotic depression (as a separate type or as a more severe expression of depression) remains unclear; that delusions, hallucinations and severe psychomotor disturbance have high cross-sectional diagnostic weighting (while longitudinal information is of importance); that determinants include both genetic and organic factors; that most patients with this condition require admission to hospital; and that bilateral ECT is the most effective treatment. The answers to the questionnaires established areas where the audience did not modify their responses because they were already well-informed, others where their views were considerably changed (e.g. “psychotic’ episodes in those with a borderline personality disorder) and others where they modified their clinical reasoning (e.g. “if a “psychotic’ feature is mood-congruent then the condition must be an affective disorder’ became “if the patient has an affective disorder, the psychotic feature must be mood-congruent’). Finally, we make some recommendations for future consensus conferences.

Intravenous Sedation of Involuntary Psychiatric Patients in New South Wales

Objective: Intravenous sedation of involuntary psychiatric patients is practised in almost all hospitals in New South Wales. Despite its widespread use, little has been published about the medications used or their safety and efficacy. The present study reports the frequency and reasons for intravenous sedation, the medications used, and the incidence of adverse effects. Method: Eighteen of 21 acute psychiatric admission units in the State were reviewed. The medical records of a random sample of 495 patients admitted involuntarily during 1990 were examined and information from the progress notes, drug charts and physical observations was recorded and subjected to statistical analysis. Results: Of the 495 patients, 132 (27%) were intravenously sedated. Eighty-six per cent (86%) of patients received a combination of haloperidol or diazepam, usually 20 mg of each drug. The threat of violence was the most significant patient characteristic predicting the use of intravenous sedation. Patients with mania or intoxication were relatively more likely to be intravenously sedated than other diagnostic categories. Patients admitted via accident and emergency departments and those admitted to teaching and metropolitan general hospitals compared to rural and large psychiatric hospitals were significantly more likely to receive intravenous sedation. The most common complications of intravenous sedation were dystonia (37%), hypotension (8%) and confusion (5%). The incidence of phlebitis and other extrapyramidal side-effects was probably under-reported. Conclusion: About one in four involuntary psychiatric patients receive intravenous sedation in NSW. Intravenous sedation is more likely when patients are admitted through accident and emergency departments to teaching or metropolitan hospitals, and pose a threat of violence. Intravenous sedation was shown to be a safe procedure given certain precautions.

Disgust with Life in General

A syndrome is described which consists of three symptoms: a mood disturbance of fear and sadness, an inability to do anything useful, and an insensitivity to pain and pleasure. Since the fourth century this condition has been known as acedia. The arguments are reviewed for its distinction from mild depression. It is suggested that the condition may be due to a lack of satisfying work.

A Point Prevalence Study of Outpatients and Inpatients in the Mental Health Services, General Hospital Psychiatric Units, and under Private Psychiatrists in Perth, Western Australia*

A one day point prevalence study of all inpatients and a one week point prevalence study of all outpatients seen by psychiatrists in Perth, Western Australia, was conducted. On the census day in July 1971, 61 per cent of all psychiatric inpatients in Perth were long-stay patients. Of the short-stay patients 75 per cent were in Mental Health Services hospitals, 17 per cent were in general hospital psychiatric units and 8 per cent were under private psychiatrists. The bed occupancy rate was 129.7 per 100,000 population for the whole State—83.2 longstay and 46.5 short-stay. These rates were low compared with published figures in other countries. The proportions of total outpatients seen during the census week by the Mental Health Services, general hospital units and private psychiatrists were 53.5 per cent, 16.0 per cent and 30.5 per cent respectively. There was a differential use of psychiatric services between immigrants and Australian-born outpatients.

Forensic Psychiatry: Clinical, Legal and Ethical Issues

Abstract Edited by John Gunn and Pamela J. Taylor. Butterworth Heinemann. Oxford, 1993; 1151 pp.; recommended retail price